Peritoneal inclusion cysts: a review.

Department of Obstetrics and Gynecology, Sloane Hospital for Women, Columbia University Medical Center, New York Presbyterian Hospital, New York, New York 10032, USA. amy.vallerie@gmail.com

OBJECTIVE: To provide a comprehensive review of peritoneal inclusion cysts in the female patient population. To define the optimal diagnostic modalities and review the medical and surgical options for management, enabling the gynecologist to individualize treatment for patients. DATA SOURCES: We searched the MEDLINE database for articles with keywords "peritoneal inclusion cyst" and "benign (multicystic) mesothelioma." Our search was limited to the English language. All reports included a tissue-confirmed diagnosis, except 1. Case reports and case series with adolescent and adult patients were reviewed. METHOD OF STUDY: We evaluated all studies meeting our criteria for clinical features, histologic criteria for diagnosis, imaging and laboratory studies, and treatment modalities. TABULATION, INTEGRATION, AND RESULTS: Fifty-two descriptive studies and 1 prospective cohort study meet criteria for review. Eleven articles focused on imaging modalities. Nineteen articles depicted histopathology. Eight addressed treatment modalities. Conclusion: This is a comprehensive review of peritoneal inclusion cysts. We specifically focus on the method of diagnosis and management. There is no standard algorithm by which the patients are evaluated, treated, or followed up. Peritoneal inclusion cysts have minimal mortality but high morbidity. Diagnosis is made by clinical history, ultrasound imaging, and CA-125 correlation. Magnetic resonance imaging is useful if ultrasound is unclear. Tissue sample is necessary for definitive diagnosis. Prior studies have suggested that cure is only accomplished with surgical resection; however, patients have a 50% risk of recurrence. We suggest that the goal for such a chronic disease should not be cure, but symptomatic relief through individualization of treatment. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to summarize imaging characteristics of peritoneal inclusion cysts, explain the epidemiology and risk factors for the development of peritoneal inclusion cysts, and describe possible treatment options for peritoneal inclusion cysts.

PMID: 19386139 [PubMed - indexed for MEDLINE]

Term

Peritoneal inclusion cysts

Background

Definition

Bakcgorund

Peritoneal inclusion cysts are aggregate masses of variable sized, fluid-filled, mesothelial-lined cysts of the abdomino-pelvic cavity. Also known as “benign (multi) cystic peritoneal mesotheliomas,” “inflammatory cysts of the peritoneum,” “postoperative peritoneal cysts,” and “benign papillary peritoneal cystosis,” history of abdominal or pelvic surgeries or inflammation. Peritoneal inclusion cysts are thought to arise secondary to intra-abdominal inflammation and subsequent cyst formation, with serous fluid derived from the ovarian stroma. The etiology and nature of the disease process are not well understood and continuously debated. Evidence suggests that hormone shifts influence the disease course. Management options range from observation to surgical resection of the reproductive tract. Cure is thought to be achievable with surgical resection only. However, given the overall benign nature of this disease with appropriate imaging and CA-125 correlation, conservative management options can be considered and treatment can be individually tailored.

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Term

Peritoneal inclusion cysts

Clinical features

Definition

Peritoneal inclusion cysts

Clinical features

Clinical Features Peritoneal inclusion cysts typically occur in women with a history of prior pelvic or abdominal surgery, pelvic inflammatory disease, endometriosis, or inflammatory bowel disease in the third and fourth decade of life. Patients often present with complaints of progressive abdominal or pelvic pain and/or a subjectively palpable abdominal mass. The duration of symptoms varies from days to months (2). Other reported presentations include acute or chronic abdominal pain, acute or chronic pelvic pain, back pain, dyspareunia, hernia, early satiety, constipation, tenesmus, urinary frequency, urinary incontinence, anorexia, dysfunctional uterine bleeding, infertility, postmenopausal bleeding, and pulmonary embolism secondary to compression and venous stasis (1–36). Ten percent of peritoneal inclusion cysts are an incidental finding at the time of an unrelated abdominal surgery, imaging, or routine exam. Peritoneal inclusion cysts are estimated to account for 2% to 6% of gynecologic surgeries for adnexal masses (37,38). Peritoneal inclusion cysts are rarely noted in menopausal patients (2–3,8–12,39,40). The reported age ranges from 15 to 92 years old (1–36). Peritoneal inclusion cysts are reported in male patients with extensive surgical history, but account for 17% of reported cases (2–3,6,14–17).

These mesothelial proliferations are usually confined to the pelvis, but have also been described in the upper abdomen and retroperitoneum (3,6). They primarily adhere to the peritoneum and ovaries, but may attach to the mesentery, omentum, or gastrointestinal organ surfaces. The cyst may range in size from 1 to 30 cm (1–12,14–36,41,42). The differential diagnosis includes lymphangioma, mesenteric or omental cysts, ovarian or tubal pathology, pseudomyxoma peritonei, endometriosis, malignant mesothelioma, and adenomatoid tumors (Table 1) (2–3,7,10,16,34,36,43–47).

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Term

Peritoneal inclusion cysts

Natural History

Definition

Peritoneal inclusion cysts

Natural History The etiology of peritoneal inclusion cysts is debated in the literature. A hyperplastic origin, ie, formation as a reactive benign process to prior surgery, pelvic inflammation or gastrointestinal inflammation, is supported by the close association of these processes and prolonged persistence without progression. In addition, 10% of lesions are incidental findings on routine exam, imaging for unrelated complaints, or surgical exploration for an unrelated indication. However, despite extensive surgical resection and surgical castration, peritoneal inclusion cysts have an estimated recurrence rate of 50% (3). In addition, observation typically results in progressive growth and worsening of symptoms (48,49). Weiss and Tavassoli reported a death secondary to cyst growth and compressive symptoms in a 47-year-old man who refused treatment 12 years after initial diagnosis (2). This report and other examples of cyst formation in patients with no known intraperitoneal inflammatory process or prior surgery argue for a neoplastic origin (19–21). However, despite a tendency to recur, lesions do not demonstrate local or distant metastasis (45). source review articlel #1

Term

Peritoneal inclusion cysts

Histology and Intraoperative and Gross appearance

Definition

Peritoneal inclusion cysts

Histology

Microscopically, mesothelial cells are arranged in a single layer. Small areas of cells arranged in nests and cords with surrounding reactive stroma are consistent with a neoplastic nature. These features, however, are confined, consistent with benign disease. Septal walls are made up of fibrovascular tissue with lymphocytes and fibroblastic cells characteristic of reactive changes. The mesothelial cells may demonstrate squamous metaplasia and formation of connective tissues, both adaptive changes to inflammation. No nuclear or cellular atypia are identified (3–4,7,22–24,45,50–52).

Intraoperative or Gross Appearance Peritoneal inclusion cysts are thin-walled unilocular or multilocular cysts arising from the pelvic organs, sidewall or cul-de-sac. Intraoperatively, they are a confluent mass of smaller cysts or discontinuous cystic studding of the peritoneal surface. Individual cysts range from several millimeters to 9 cm in size (17), with the largest reported aggregate mass 30 cm in diameter (42). Cyst walls appear 1 to 5 mm thick with a smooth outer surface (4), and may be adherent to surrounding structures, including the ovaries, fallopian tubes, large bowel, appendix, omentum and uterus (3). They are rarely free floating in the abdominal cavity (2,22,40). Upon entry in the abdomen, cysts may rupture (4,24). Peritoneal inclusion cysts may appear to be ovarian in origin, as the ovarian surface often forms part of the cyst wall and protrudes into the cyst lumen (4–5,18). Intra-abdominal exploration often demonstrates endometriosis, healed or chronic salpingitis, tubo-ovarian abscess and/or concurrent ovarian masses, and ascites fluid (3).

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Term

Peritoneal inclusion cysts

Pathophysiology

Definition

Peritoneal inclusion cysts

Pathophysiology

A third hypothesis suggests that peritoneal inclusion cysts are the result of a low-grade or borderline malignant condition. Weiss and Tavassoli reviewed 37 cases, demonstrating adenomatoid change or squamous metaplasia in one-third of cases, supporting the idea of a continuum of mesothelial tumors rather than distinct entities (2). In comparison with other mesothelial tumors of the abdomen, peritoneal inclusion cysts demonstrate the benign cellular components of adenomatoid tumors and the symptomatic, progressive, recurrent behavior of malignant mesotheliomas (Table 2) (7,46,52).

Regardless of the origin, a predisposition to reproductive age women suggests a hormonal component to the formation, origin, and maintenance of peritoneal inclusion cysts. Further, risk for development of peritoneal inclusion cysts is seen in women with endometriosis. Additionally, no case report to date describes the diagnosis or symptoms of peritoneal inclusion cysts, while simultaneously using hormonal contraceptives. Two case reports detail the rapid growth and worsening of symptoms during pregnancy. One patient had chronic intermittent pain for several years before pregnancy, with acute exacerbation during the second trimester. A second report described surgical resection at 5 weeks’ gestation with recurrence within 6 weeks, suggesting that a hyperestrogenic state may precipitate their growth (27,53). This theory is supported by widespread estrogen receptor staining of the cyst wall removed during pregnancy (27).

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Term

Peritoneal inclusion cysts

Can they turn into cancer?

Definition

Peritoneal inclusion cysts

Can they turn into cancer?

One case report describes the transformation of a previously histologically diagnosed peritoneal inclusion cyst to a malignant mesothelioma in a conservatively managed patient. Over a 10-year course, the patient suffered multiple recurrences and tense abdominal ascites, an atypical finding for peritoneal inclusion cysts. On final laparotomy, there was diffuse disease and lymph node involvement. The patient was alive with pleural involvement 2 years after diagnosis (16,48). source: review article #1

Term

Peritoneal inclusion cysts

Cytology

Definition

Peritoneal inclusion cysts

Cytology

Cytology Peritoneal inclusion cysts contain clear to yellow serous fluid, but may contain hemorrhagic or gelat-inous discolored fluid. Normally, physiologic peritoneal fluid is produced by the ovaries and resorbed by the peritoneal surface (54). This fluid is rich in ovarian hormones and the volume and contents fluctuate with the menstrual cycle, with progressively increasing volume during the follicular phase and peaking in the early luteal phase. Postmenopausal women, women with severe endometriosis, and women on hormonal contraceptives produce less peritoneal fluid (54). Inflammation, infection, or injury to the peritoneal surface may retard its absorptive properties in addition to causing an inflammatory exudate (5). Peritoneal fluid may become encapsulated in the inflammatory reactions surrounding surgery; or the increased fluids may stimulate formation of peritoneal inclusion cysts. Cytology of peritoneal inclusion cyst fluid is usually nondiagnostic (11,25,49). Results demonstrate nonspecific reactive mesothelial cells, also found in viral infections, cirrhosis, and connective tissue disorders. A diagnostic aspiration would yield mesothelial cells with focal presence of a brush border and flattened epithelial cells (11).